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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 143-146

Comparison of omentoplasty and tube drainage as treatment option in hydatid liver disease: A retrospective hospital-based observational study


1 Department of Paediatrics, World College of Medical Sciences and Research Institute, Jhajjar, Haryana, India
2 Department of Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India
3 Department of Neonatology, World College of Medical Sciences and Research Institute, Jhajjar, Haryana, India

Date of Submission04-Dec-2019
Date of Decision24-Jan-2020
Date of Acceptance12-Feb-2020
Date of Web Publication9-Apr-2020

Correspondence Address:
Sajad Ahmad Sheikh
World College of Medical Sciences and Research Institute, Jhajjar, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_115_19

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  Abstract 


BACKGROUND: Hydatid disease remains an important parasitic infection requiring surgical intervention. The liver is the most common site of infection, and several methods of surgery have been described to treat this common disease. Extensive research is going on to find the best operative treatment procedure for hydatid liver diseases.
AIM: The aim of the study was to compare the results of two surgical methods used in the treatment of hydatid disease of the liver, namely omentoplasty and tube drainage.
MATERIALS AND METHODS: Fifty-seven cases of hydatid liver were treated from January 2005 to January 2011, out of which thirty patients were treated with omentoplasty (Group A) and 27 were treated with tube drainage (Group B). The results of the surgery in terms of mortality, complications, hospital stay, and recurrences were analyzed by unpaired t-test or Fisher's exact test, and P value was calculated.
RESULTS: Overall postoperative complications were seen in 9.4% in Group A and 22.5% in Group B. The average hospital stay and time to resume routine work in Group A was shorter as compared to Group B. The percentage of complications such as wound infections and abscesses formation were 3.4% each in omentoplasty group and 11.2% and 7.2% in tube drainage group, respectively. The comparison of infection frequency among two groups showed strong statistical significance withP = 0.002 in wound infection and 0.0014 in abscess formation. The comparison of jaundice development after both procedures was statistically insignificant (P = 0.037). No patient in omentoplasty group developed biliary fistula, and the percentage of this complication in tube drainage was 3.7%. The recurrence of hydatid disease in omentoplasty was nil and 7.41% in tube drainage patients. There were no recurrences in either group for a follow-up of 4 years.
CONCLUSION: Omentoplasty is better and must be preferred operative procedure than tube drainage in the treatment of hydatid cyst liver disease.

Keywords: Echinococcus, hydatid cyst, omentoplasty, tube drainage


How to cite this article:
Bhat JA, Akhter S, Sheikh SA. Comparison of omentoplasty and tube drainage as treatment option in hydatid liver disease: A retrospective hospital-based observational study. Int J Health Allied Sci 2020;9:143-6

How to cite this URL:
Bhat JA, Akhter S, Sheikh SA. Comparison of omentoplasty and tube drainage as treatment option in hydatid liver disease: A retrospective hospital-based observational study. Int J Health Allied Sci [serial online] 2020 [cited 2020 Jun 3];9:143-6. Available from: http://www.ijhas.in/text.asp?2020/9/2/143/282130




  Introduction Top


Hydatid cyst of the liver is a zoonotic disease caused by the larval stage of Echinococcus granulosus.[1],[2] Humans are accidental intermediate hosts, whereas animals are both the intermediate and the definitive hosts.[3],[4] The two most common types of hydatid diseases are caused by E. granulosus and Echinococcus multilocularis.[5],[6] Worldwide, the disease is commonly seen in the Mediterranean region, South America, the Middle East, Australia, and New Zealand. It is the most common type of hydatid infection in humans. The involvement of almost every organs and body tissues by the hydatid infection is known in literature, but the liver remains the most common organ to be involved. About 50%–75% of the cysts occur in the liver, 25% are located in the lungs, 7% in the kidney, and 5%–10% distributed along the vascular system.[7],[8],[9] The outer covering of the cyst called the pericysts is an outer fibrous capsule derived from the host tissue as a result of inflammatory reaction. The cyst wall is composed of two layers. Ectocyst is an outer gelatinous membrane and an endocyst is an inner germinal membrane. Brood capsules are intracellular masses in which future worms develop into scolices. In a definitive host, the scolices develop into an adult worm. In the intermediate host, they differentiate into a hydatid cyst. Hydatid sand is the free brood capsules, and scolices are found in the hydatid fluid. Death of the hydatid cysts can lead to degeneration of the membrane and calcification of the cyst wall.

The life cycle of E. granulosus has two hosts. The definitive host is usually a dog or some other carnivore. The adult worm lives in the proximal small bowel of the definitive host attached to gut wall mucosa by hooklets. Eggs are released and excreted in the feces. Sheep are the most common intermediate host. These animals get infected while grazing in the fields. The ovum once ingested loses the protective chitinous layer in the upper digestive tract of the host. The released hexacanth embryo (oncosphere) gains entry into the portal circulation after passing through the intestinal wall and develops into cysts in the liver ( first filter). The definitive host (e.g., dog) eats the infected viscera of the intermediate host and the cycle is completed.[10],[11]

Radiological investigations such as ultrasonography and contrast-enhanced computed tomography (CECT) identify the cyst in >90% of the cases. CECT provides characteristic images based on its wall features, daughter cysts, septations, calcification, and communication with the biliary channels.[12],[13],[14]

Surgery is the basic treatment for hepatic hydatid disease. The main objectives of surgical treatment are:

  1. Eradication of the parasite
  2. To prevent spillage of contents during the surgical procedure
  3. Obliteration of the residual cyst cavity.


Various surgical procedures exist to achieve these goals.[15],[16],[17] Till date, surgical exploration remains the treatment of choice in the management of hydatid disease.[16],[17] The treatment of the residual cyst cavity of the hepatic hydatid disease is a debatable issue and generally has not produced any consensus. Two main operative approaches have been described: (a) drainage procedures and (b) the obliteration of the residual cyst cavity after evacuation of the cyst content (omentoplasty). The main objective of our study was to compare these two procedures (omentoplasty and tube drainage) and determine which one is better for treatment of pediatric hydatid liver disease.


  Materials and Methods Top


This prospective hospital-based observational study was conducted on 57 cases of hydatid liver who were treated in the Department of Surgery, Government Medical College, Srinagar, Kashmir, from January 2005 to January 2011. Patients were categorized into two groups. Group A patients treated with omentoplasty and Group B treated with tube drainage. A total of thirty patients were included in Group A and 27 into Group B. The diagnosis of hydatid liver was made by ultrasonography or computed tomography scan [Figure 1]a and [Figure 1]b. Proper ethical and scientific clearance was taken from respective committees before conducting this research. Informed consent was obtained from every patient after explaining risk and benefits of each procedure and purpose of our research.
Figure 1: (a and b) Contrast-enhanced computed tomography scan pictures of hydatid cyst liver

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Detailed history and physical examination was done before subjecting the patients to surgical exploration. All the patients were subjected to enzyme-linked immunosorbent assay for hydatid disease. Patients were kept fasting overnight, and informed consent was obtained before subjecting them to operation. After opening the abdominal cavity, the operative field was protected against the spills by packs soaked with 10% of povidone-iodine, the cystic fluid was removed using a closed suction system, and the cystic cavity was filled with 10% of povidone-iodine for about 10 min. After incising the ectocyst, the endocyst containing the daughter cysts was completely removed. The cyst cavity was cleaned by dry gauze, and any biliary communication was looked for. Visible communications between the remaining cavity and the biliary ducts were closed with fine sutures.

These two techniques were compared with reference to average length of hospital stay, average days taken for resumption of normal activities, complications such as infection (wound infection and abscess formation), jaundice, and recurrence of hydatid liver disease. The recurrence was checked by clinical examination, ultrasonography (USG), and serological tests every 3 months.

Statistical analysis

All the data collected were analyzed using IBM SPSS Statistics for Windows, Version 23.0. (IBM Corp., Armonk, NY, USA) and MedCalc Software 18.11.3 (Acacialaan 22, 8400 Ostend, Belgium). Unpaired Student's t-test and Fisher's test were used to compare data and derive P value. P < 0.005 was considered statistically significant.


  Results Top


Out of 57 patients included in our study, 35 were male and 22 were female with a mean age of 34.2 ± 6.5 years for males and 33.6 ± 5.9 years for females. Age was compared and showed no statistical difference. The sizes of the cysts ranged from 6 to 10 cm. Thirty patients (Group A) were treated with omentoplasty technique and 27 (Group B) with the tube drainage. The average length of hospital stays, average days taken for resumption of normal activities, postoperative complications such as wound infection, abscess formation and jaundice, and recurrence over follow-up period of 4 years were compared in these two groups [Table 1].
Table 1: Comparative parameters of two surgical techniques for hydatid cysts (Group A omentoplasty patients and Group B tube drainage patients)

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Mortality was recorded in no patient during intraoperative and postoperative period. However, one patient did not reported to follow-up after 6 months because of unknown reason as shown in [Table 1]. [Table 1] also shows that statistics of average days of hospital stay and average days to resume normal work in Group A were 8.7 ± 2 and 14.6 ± 3 and in Group B were 18.4 ± 4.5 and 21.2 ± 5, respectively. The comparison of these parameters among groups was also statistically significant with P = 0.0001 for average days of hospital stay and P = 0.004 for average days to resume normal work.

Wound infection occurred in 1 (3.4%) patient of Group A and 3 (11.2%) patients of Group B, and statistical relation of this complication was significant with P = 0.002. Intraabdominal abscess formation occurred in 1 (3.4%) patient of Group A and in 2 (7.4%) patients of Group D again, statistically relation with respect to this complication was also significant (Value 0.0014 ≤ 0.005). Jaundice occurred in 2 (6.8%) in Group A patients and 3 (11.2%) of Group B patients. However, comparison of jaundice in both groups shows no statistical significance (value 0.073 ≥ 0.005). No patient in Group A and 1 (3.7%) patient in Group B developed biliary fistula. However, the comparison of the development of this complication showed no statistical significance (P = 0.072).

On follow-up, the recurrence of hydatid cyst in the liver after operation was not reported in any patient in Group A and 2 (7.7%) of the patients of Group B with statistical significance (P = 0.001).

Overall complication rate in Group A patients was 13.3% and in Group B was 41.2%. The complication rate in Group A was lower as compared to Group B and showed statistical significance with P = 0.012 [Table 1].


  Discussion Top


Due to poor sanitation, hepatic hydatid cyst is still an endemic health problem in many countries of the developing world.[18] Clinical symptomatology varies considerably depending on the size and anatomical location of the cyst. Most common presenting symptoms in our series were pain in the right upper quadrant, nausea, and vomiting. Physical examination showed minimal findings. Hepatic hydatidosis is one of the differential diagnoses of patients of endemic areas presenting with vague symptoms of pain and mass in upper abdomen, nausea, and vomiting.[19],[20]

In our study, we found that the average hospital stay and average days taken to resume normal routine work were both shorter in omentoplasty group as compared to drainage procedure group. Similar findings were reported by Akin et al.,[21] Gourgiotis,[22] and Wani et al.[23]

In our study, complication rate and formation of the biliary fistula was high in drainage procedure group as compared to omentoplasty group. Similar findings were noted by Reza Mousavi et al.[4] and Wani et al.[23] in their studies. The longer stay, longer work resuming time, and high infection rate can be explained by additional tube drain in the abdomen in drainage procedure which interfered with early ambulation, and the drain can be important factor in the entrance of microorganisms into the peritoneum, thus increasing peritoneal infections. The second factor which can contribute to decreased rate of infection rate in omentoplasty group can be vascularized flap of omentum which obliterates the cavity, absorbs any secretions present there, and also contributes to innate immunity.[24]

An important finding which we noted in our study is high recurrence rate in case of tube drainage procedure. This finding was also noted by Wani et al.[23] in their study. This decreased risk of recurrence can be attributed to protective properties of omentum, assistance in healing of raw surface and promoting resorption of serosal fluid.[25]

Since no single method has been recommended for the treatment of hydatid cysts which show precedence over another, advocates of tube drainage prefer it is technically easier to perform, takes lesser time and identifies biliary leaks and other prefer omentoplasty because of its shorter postoperative stay, less chances of infection and recurrence. Our study also supports the view preference of omentoplasty over tube drainage because we saw less infectious percentage, shorter stay, early resumption of routine work, and less recurrence.


  Conclusion Top


Omentoplasty is better operative procedure than tube drainage in the treatment of hydatid cyst liver because it is safe, has less infective rate, less chances of biliary fistula, and less long-term recurrence.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ertem M, Uras C, Karahasanoglu T, Erguney S, Alemdaroglu K. Laparoscopic approach to hepatic hydatid disease. Dig Surg 1998;15:333-6.  Back to cited text no. 16
    
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Gourgiotis S, Stratopoulos C, Moustafellos P, Dimopoulos N, Papaxoinis G, Vougas V, et al. Surgical techniques and treatment for hepatic hydatid cysts. Surg Today 2007;37:389-95.  Back to cited text no. 22
    
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